R-5662•
OFFICE COPY
PERMIT R_
5662_J
APPLICATION FOR CITY OF CUPERTINO NUMBER .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
0 S
l
RESIDENTIAL COMMERCIAL OTHER-
OWNERSx
HAZARDOUS FIRE AREA
1
YES ❑ IFyes -emblyunderstandrequired ClassA
NAME �% I<_J�,C.a�l /� \
roof assembly is required.
NO Initial I.C.B.O. M
E F E N
ADD SS
\
NUMBER OF EXISTING COVERINGS
PHO J �F-✓
CONTRAC R'S
TO BE REMOVED TO BE RETAINED
NAME V
ADDRESSL �n ` , ,�
�-, TYPE OF ROOF COVERING
CITY & 71P WYE
EXISTING _
t
L49/; t ����
_
BUILT-UP ROOF ❑CENSr
IP,,HONE
IiIUMBER_
ASPHALTSHINGLES ❑
LICENSED ONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
J�
effect.
SHINGLES El
License Class Lic. Number
OTHER (SPECIFY) ❑
Date oniractor
O E BUILDERD A ION
I here y at i m that I em exempt from the Contractor's License Lew for the bIlowing reason.
TR;-QSED �.Q Q
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a perm11 to
'
repair any structure, prior to its issuance, also requires
construct, alter, Improve, tlfilea
BUILT-UP ROOF U/ y,❑
ovisithe
sigr
for such permit to file a signal statement that he Is licensed pursuant to the provisions
of the Division 301 the
License Law (Chapter h (commencing with therefrom
of the ss and and ]000) basis
Business antl Professions Code) or that he Is exempt and the basis for the alleged
ASPHALT SHINGLES,
exemption.Any violation on any ant for a permit subjects the applicant to
applicant
1 tq-
Our�
lty of a than five undyed s ($5 ):
e c0, penalty of net more then floe hundred dollars (h
WOOD SHAKES
wag
I,esowner ofthe property, or employeeswith wages as their Bole compensation, will
to s.
the work, and the structure Is not Intended or offered for eels (Sec. 7064, Business and Profen
'
all Code: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES ❑
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR.IN$TALLATION SPECS.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
,
Owner Data
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
- -
I hereby affirm under penalty of perjury one of the fallowing declaration:
of Consent to self -insure performa for Worker's Compensation ton,
❑ have and will maintain a of the
as for by Section 3700 of Iha Labor Code, for the performance of the work for which ibis1(7-_I
` I
Bui din
mit Is Is
permit le Issued.
I O�� O
Seismic t'
❑ have and will maintain Worker's Compensatl Insurance, es required by Sedlon 3700 cl
the Labor Coda, for ha performance of the work r which this rmit le Isauetl. My Worker's
Total
Com ns I n 1 r nce errier olicy numb ere: /�—
Carr Policy N l
PERMIT AUTHORIZATION
D
CERTIFICATE OF EXEMPTION FROM WORKE s'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for One hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
shy person any man er so as to become subject to the Workers' mpensatlon Laws of Celb
All roofs Shall be inspected prior to any roofing material being
orM
I
installed. If a roof is installed without first obtaining an
Data Applicant � /�7`�
�
inspection, I agree to remove all new materials for inspection.
subjecttooEtheworkers c mpeosatlonprovisionisatethefiLaborrCotle,cate of yolumustforthwlithbecome
comply
Applicant understands and will comply with all non point
with such provisions or this permit shell be doomed revoked.
source regulations.
I certify that I have read this application and state that the above Information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class "C"or better.
herebspeotiy
hereby authorize representatives Of this city to enter upon the above-mentioned property for ImSIGNATUREI
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against Ilebllltles,
judgments, costs and expenses which may in any way accrue against said City In consequence
SIGN TURE OF
of the granting of this permit.
APPLICANT DA E
PRE -INSPECTION:
PLYWOOD:
IN. -PROGRESS:
INSP. DATE
INSP.—DATE—
INSP.—DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
E
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SUBJECT: REROOFING POLICY FOR T'r:E CITY OF CUPERTNO BUII.DL`+G DE?A.RTMENT
PRIOR TO ISSUANCE OF PERMIT AND LNSPE.. t ION PILkSR-
1. Poor to pe mit issuancq you must a, r_ to comply with U.B.C. standards and manuf=Urers spec's
on reroofing.
2. Ne,.v roof coverings stall not be applied without first obtaining all inspection and NNTiren acoroval
from the building inspector. A final ince- ion and approval shall be obtained Pram the building
i=cctor when the retooling is completed.
3. All types of roof shall be inspe^_ted prior to any roof being installed-
4.
nstalled4. In order to receive a final, you mut complete steps 1, 2, and 3.
1,) P:einsoecdon or tear off aeprovrl.
2.) In progress inrpec ion approval.
3.) Final inspection approval.
a.) Operable smoke del --tar verification
b.) Spark arrector installation
5. If plywood is installed, a plvwced nail inispecdon is required
6. If any roof is auolied without first obtaining an i n pectron, you will be required to remove all new
mate al down to the sheathing and a biuldm-pe= or will inre�_, all sheathing at that time.
g in
WE UNDERSTAND Tr ABOVE POLICY ON REROOFING A_ND WU-L COMPLY WIIF_ lzrE
POLICY
EO,vMOWNERS NAVE:
ADDRESS:
REROOFING CObtPANY NAME:
APPLICANT'S SIGNATURE:
CII'! OF CUPERTINO
BUILDING DEPARTMENT
Rerooftwinword
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